gagal jantung - dr. andreas arie, sppd-kkv
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kuliah gagal jantungTRANSCRIPT
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HEART FAILURE
Dr. Andreas Arie, SpPD-KKV
CARDIOVASCULAR DIVISION INTERNAL MEDICINE DEPARTMENT
MEDICAL FACULTY DIPONEGORO UNIVERSITY
DEFINISI GAGAL JANTUNGDEFINISI GAGAL JANTUNG
- suatu keadaan patofisiologis di mana jantung tidak mampu memompa darah sesuai kebutuhan metabolisme jaringan, atau untuk memenuhi kebutuhan jaringan harus meningkatkan tekanan pengisian.
- gagal jantung adalah suatu sindroma klinik yang kompleks akibat gangguan fungsional/ struktural jantung yang mengganggu kemampuan pengisian/ memompa ventrikel.
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DEFINISI GAGAL JANTUNGDEFINISI GAGAL JANTUNG
Gagal Jantung merupakan akhir dari beberapa penyakit jantung :
PENYAKIT JANTUNG BAWAAN
PENYAKIT JANTUNG KATUP
PENYAKIT JANTUNG KARDIOMIOPATI
PENYAKIT JANTUNG KORONER
PENYAKIT JANTUNG HIPERTENSI
LV dilatation
Activation of Neurohormonal Pathways in HFActivation of Neurohormonal Pathways in HF
Coronary Disease Cardiomyopathy Cardiac Overload
Left Ventricular Dysfunction
Neurohormonal Activation• Cathecholamines• RAS• AVP• Endothelin
Cardiac RemodellingPeripheral OrganBlood Flow
Vasoconstriction
skeletalmuscle flow
RBFNa+ retention
LV hypertrophy
Arrhythmias
Exercise Intolerance Edema, Congestion Sudden Death Pump Failure
Ruffolo, J Cardiovasc, Pharmachol, 1998
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Pathophysiology of CHFPathophysiology of CHFInjury to myocytes
and EC matrix
Electrical, vascular, renal,pulmonary, muscle effects
CHF
Ventricularremodelling
Neurohumoral activationIncreased cytokines
Immune andinflammatory changes
altered fibrinolysis
Oxidative stressApoptosis
Altered geneExpression
Energy starvation
McMurray J, Pfeffer M. Circulation. 2002 (in press)
• Neurohormonal stimulation
• Endothelial dysfunction
• Vasoconstriction
• Renal sodium retention
Progression of Cardiovascular DiseaseProgression of Cardiovascular DiseaseCoronary
arterydisease
Hypertension Arrhythmia
Left ventricularremodeling Remodeling Low ejection
fraction Death
PumpfailureCardiomyopathy Valvular
disease
(Abraham, 2000)
Noncardiacfactors
Symptoms:DyspneaFatigueEdema
Chronicheart
failure
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Framingham criteria for Congestive Heart Failure
Definite : - 2 major
- 1 major + 2 minor
Major Criteria Minor Criteria
Paroxysmal nocturnal dyspnea
Neck-vein distension
Rales
Acute pulmonary edema
S3 gallop
Increased venous pressure
> 16 cm H2O
Circulation time > 25 sec
Hepatojugular reflux
Ankle edema
Night cough
Dyspnea on exertion
Hepatomegaly
Pleural effusion
Vital capacity increased 1/3 from
maximun
Tachycardia ( rate > 120/min)
Major or Minor Criteria
Weight loss > 4.5 kg in 5 days in response to treatment
Gagal Jantung
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New York Heart Association Functional ClassificationClass I: No symptoms with ordinary activity
Class II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or angina
Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in
fatigue, palpitation, dyspnea, or anginal pain
Class IV: Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency may be present even at rest
NORMAL
Asymptomatic LV Dysfunction
CompensatedCHF
DecompensatedCHF
No symptomsNormal exerciseNormal LV fx
No symptomsNormal exerciseAbnormal LV fx
No symptomsExercise
Abnormal LV fx
SymptomsExercise
Abnormal LV fx
RefractoryCHF
Symptoms not controlled with treatment
Chronic Congestive Heart Failure
Evolution of Clinical Stages
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Stages Examples
Stage A: At high risk for HF but without structural heart disease or symptoms of HF
HTN, CAD, DM, cardiotoxins, FHx of CM
Stage B: Structural heart disease but without symptoms of HF
Previous MI, LV systolic dysfunction, asymptomatic valvular disease
Stage C: Structural heart disease with prior or current symptoms of HF
Known structural heart disease, SOB and fatigue, reduced exercise tolerance
Stage D: Refractory HF requiring specialized interventions
Marked symptoms at rest despite maximal medical therapy
Stages of Heart Failure
ACC/AHA Heart Failure Practice Guidelines 2001
Klasifikasi Killip: (klinis)
�� Stadium IStadium I : tak ada tanda-tanda gagal jantung (IMA 85%)
�� Stadium IIStadium II : didapat tanda-tanda gagal jantung
awal berupa ronki di paru, gallop S3.
�� Stadium IIIStadium III : gagal jantung berat yaitu terjadi
edema pada seluruh lapangan paru
�� Stadium IVStadium IV : terjadi syok kardiogenik berupa
hipotensi (tekanan sistolik < 90
mmHg), nadi cepat, ekstremitas
dingin, oliguria, sianosis.
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DIET Approach to the Patient With Heart Failure
• Diagnose– Etiology
– Severity (LV dysfunction)
• Initiate– Diuretic/ACE inhibitor
– β-blocker
– Spirololactone
– Digoxin
• Educate– Diet
– Exercise
– Lifestyle
– CV Risk
• Titrate– Optimize ACE inhibitor
– Optimize β-blocker
The Clinical History in Heart Failure Specific History to Obtain*
• Cardiovascular
� Angina Pectoris
� Nonspesific chest pain
syndromes
� Fatique
� Weakness
� Orthostatic faintness
� Palpitations
� Rheumatic disease
� Congenital disease
• Pulmonary
� Dyspnea on exertion (DOE)
� Orthopnea (OP)
� Paroxysmal nocturnal dyspnea (PND)
� Periodic respirations
� Nocturnal apnea
� Snoring
� Pleurisy
� Cough
� Hemoptysis
� Wheezing
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• Gastroenterologic
�Abdominal pain
�Abdominal bloating
�Constipation / diarrhea
�Anorexia
� Nausea
�Vomiting
• Neurologic
�Anxiety or panic
� Depression
�Confusion
� Decreased mental acuity
• Renal
� Nocturia
�Oliguria
• Systemic
� Edema
� Petechiae / ecchymosis
�Weight gain / loss
Specific History to Obtain*
Physical examination of Heart Failure PatientsSpecific physical findings to pursue*
•Vital sign
� Positional blood pressure
� Blood pressure response
during valsalva
� Pulse rate, rhythm, and quality
� Respiratory rate and pattern
�Temperature
• Cardiovascular
� Neck vein distention
�Abdominal-jugular neck vein reflex
�Cardiomegaly on palpation
� Displaced, sustained, or
hyperkinetic apical impulse
�Chest wall pulsatile activity
�Gallop rhythm on auscultation
� Heart murmur (especially mitral,
tricuspid, and pulmonic insuf.)
� Diminished S1 or S2
� Friction rubs
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PENUNJANG
� Lab :
Leucocytosis, Urine : Oligouria
� ECG :
Dysrythmia, LVH, RVH, IHD, Tachicardia,
� Chest X-Ray :
� Cardiomegaly
� Inceased Bronchovascular Marking
� Alveolar Edema
� Pleural Efusion
� ‘Bat-Wing’ App / Kerley B-Lines
� Echocardioghraphy
Suspected acute heart failureAssess symptoms and signs
Consider other
diagnosis
normalHeart disease ?ECG / X-ray / BNP/NT-proBNP ?
abnormal
Evaluate cardiac function by echocardiography/other imaging
… continue
ESC guidelines on the diagnosis of acute heart failure
abnormal
normal
European Heart Journal 2005; 26:1115
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Stages in the evolution of HF and recommended therapy by stageStages in the evolution of HF and recommended therapy by stageStages in the evolution of HF and recommended therapy by stageStages in the evolution of HF and recommended therapy by stage
Pts with:• Hypertension• CAD• DM• Cardiotoxins• FHx CM
THERAPY
• Treat Hypertension• Stop smoking
cessation• Treat lipid disorders• Encourage regular
exercise• Stop alcohol &
drug use• ACE inhibition
THERAPY
• All measures under stage A
• ACE inhibitor• Beta-blockers
THERAPY
• All measures under stage A
• Drugs for routine use:• diuretic• ACE inhibitor• Beta-blockers• digitalis
THERAPY
• All measures under stage A, B and C
• Mechanical assist device
• Heart transplantation• Continuous IV
inotrophic infusions for palliation
Stage A Stage B Stage C Stage D
Struct.Heart
Disease
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult 2001
Pts with:• Previous MI• LV systolic
dysfunction• Asymptomatic
Valvular disease
Develop.Symp. of
HF
Pts with:• Struct. HD• Shortness of
breath and fatigue,reduce exercisetolerance
Refract.Symp. ofHF at rest
Pts who havemarked symptomsat rest despitemaximal medicaltherapy
The Donkey Analogy
Ventricular dysfunction limits a patient's ability to perform the routine activities of daily living…
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Digitalis Compounds
Like the carrot placed in front of the donkey
Diuretics, ACE Inhibitors
Reduce the number of sacks on the wagon
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Management of Heart FailurePrimary Targets of Treatment in Heart Failure.
ATAS PERHATIANNYAATAS PERHATIANNYAATAS PERHATIANNYAATAS PERHATIANNYA